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Preliminary cone-beam computed tomography

study evaluating dental and skeletal changes
after treatment with a...

Article in American journal of orthodontics and dentofacial orthopedics: official publication of the American
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Preliminary cone-beam computed

tomography study evaluating dental and
skeletal changes after treatment with
a mandibular Schwarz appliance
Kiyoshi Tai,a Hitoshi Hotokezaka,b Jae Hyun Park,c Hisako Tai,d Kuniaki Miyajima,e
Matthew Choi,f Lisa M. Kai,g and Katsuaki Mishimah
Mesa, Ariz, Okayama and Nagasaki, Japan, Seoul, Korea, St Louis, Mo, Paterson, NJ, and Los Angeles, Calif

Introduction: The purpose of this study was to evaluate the efficacy of the Schwarz appliance with a new
method of superimposing detailed cone-beam computed tomography (CBCT) images. Methods: The subjects
were 28 patients with Angle Class I molar relationships and crowding; they were randomly divided into 2 groups:
14 expanded and 14 nonexpanded patients. Three-dimensional Rugle CBCT software (Medic Engineering,
Kyoto, Japan) was used to measure 10 reference points before treatment (T0) and during the retention period
of approximately 9 months after 6 to 12 months of expansion (T1). Cephalometric and cast measurements
were used to evaluate the treatments in both groups. Also, the mandibular widths of both groups were
measured along an axial plane at 2 levels below the cementoenamel junction from a CBCT scan. Differences
between the 2 groups at T0 and T1 were analyzed by using the Mann-Whitney U test. Results: The dental
arch (including tooth root apices) had expanded; however, alveolar bone expansion was only up to 2 mm below
the cementoenamel junction. There was a statistically significant (P \0.05) difference between the groups in
terms of crown, cementoenamel junction, root, and upper alveolar process. However, no significant (P .0.05)
differences were observed in the interwidths of the mandibular body, zygomatic bones, condylar heads, or man-
dibular antegonial notches. In the mandibular cast measurements, arch crowding and arch perimeter showed
statistically significant changes in the expanded group. The buccal mandibular width and lingual mandibular
width values had significant changes as measured from a point 2 mm below the cementoenamel junction.
Conclusions: The findings suggest that the Schwarz appliance primarily affected the dentoalveolar complex,
but it had little effect on either the mandibular body or any associated structures. In addition, the molar center
of rotation was observed to be below the root apex. (Am J Orthod Dentofacial Orthop 2010;138:262.e1-262.e11)

T
he maxilla has a midpalatal suture, but the man-
dible does not. Therefore, rapid maxillary expan-
sion increases the transverse dimension of the
maxillary arch by separating the suture, 1-4 whereas the
effects of mandibular expansion are localized to
alveolar bones and mainly induce tooth inclination.2,5
For lateral expansion of the mandible during mixed
dentition, appliances with expansion screws, such as
the Schwarz appliance,6,7 have been widely used.8 Al-
though expansion of the mandible has theoretically
never been successful, several studies have reported
good clinical results with the technique.9-18

a f
Visiting adjunct assistant professor, Postgraduate Orthodontic Program, Ari-
zona School of Dentistry & Oral Health, A. T. Still University, Mesa, Ariz; post-
graduate student, Department of Oral and Maxillofacial Reconstructive Surgery,
Graduate School of Medicine, Dentistry and Pharmaceutical Sciences,
Okayama University; private practice, Okayama, Japan.
b
Senior assistant professor, Department of Orthodontics and Dentofacial
Orthopedics, Graduate School of Biomedical Sciences, Nagasaki University,
Nagasaki, Japan.
c
Associate professor and chair, Postgraduate Orthodontic Program, Arizona
School of Dentistry & Oral Health, A. T. Still University, Mesa, Ariz; interna-
tional scholar, Graduate School of Dentistry, Kyung Hee University, Seoul,
Korea.
d
Postgraduate student, Department of Oral and Maxillofacial Reconstructive
Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences,
Okayama University; private practice, Okayama, Japan.
e
Adjunct professor, Center for Advanced Dental Education, Saint Louis Univer-
sity, St Louis, Mo.
Assistant clinical professor, Department of Dentistry and Oral Maxillofacial
Surgery, St Josephs Regional Medical Center, Paterson, NJ.
g
Resident, Graduate Orthodontic Department, University of Southern Califor-
nia, Los Angeles.
h
Senior assistant professor, Department of Oral and Maxillofacial Reconstruc-
tive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sci-
ences, Okayama University, Okayama, Japan.
The authors report no commercial, propriety, or financial interest in the products
or companies described in this article.
Reprint requests to: Jae Hyun Park, Postgraduate Orthodontic Program, Arizona
School of Dentistry & Oral Health, A. T. Still University, 5855 E Still Cir, Mesa,
AZ 85206; e-mail, JPark@atsu.edu.
Submitted, September 2009; revised and accepted, February 2010.
0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.02.023

262.e1
262.e2 Tai et al
However, gaining space in the mandibular arch has
been a limiting factor because of the belief that the ex-
pansion is not stable. Reidel19 stated that arch form, par-
ticularly in the mandibular arch, could not be altered by
appliance therapy. Intercanine and intermolar widths
tend to decrease during the postretention period, espe-
cially if they were expanded during treatment.19-21
Average mandibular intercanine widths have been
reported to be 24 to 26 mm, suggesting possibly
a biologically optimal range for achieving stability.22
Several reports contend that moderate increases in
arch width are possible, especially in the anterior re-
gions of the arches, until the permanent canines
erupt.8,23-30 After this, arch width usually decreases in
both anterior and posterior regions. In contrast,
Walter29 concluded that mandibular arch width could
be expanded permanently. Lutz and Poulton31 also re-
ported that, during the early mixed dentition, if the den-
tal arches are expanded in patients with crowding, the
path of eruption of the mandibular permanent canines
and premolars can be altered to the increased width.
Furthermore, they found that the increased maxillary
and mandibular deciduous second molar width can be
maintained. However, the increased maxillary and man-
dibular deciduous canine widths tend to return to the
widths before treatment without retention appliances.
Motoyoshi et al32 also found that retention duration is
the most important factor for maintaining the expansion
effect. Although the literature has provided little guid-
ance for predicting which patients can tolerate greater
expansion, certain malocclusions seem to have greater
potential for retaining some increase in arch width.21
In addition, Schulhof33 derived a formula indicating
that a patient with a brachyfacial pattern will have
a wider arch than the dolichofacial type.
However, a method to objectively evaluate mandib-
ular shape change has not yet been developed. Cur-
rently, analysis methods have been with cast models
or cephalometric radiographs.34-36 Therefore, we have
devised a new method of superimposing images from
cone-beam computed tomography (CBCT) to evaluate
the changes in mandibular shape. The purpose of this re-
search was to analyze the efficacy of the Schwarz appli-
ance with this method of CBCT imaging.
MATERIAL AND METHODS
The subjects comprised 28 patients from a private or-
thodontic office who were diagnosed with Angle Class I
malocclusions with crowding and normal vertical
dimensions and no posterior crossbites. The study was
approved by the Kansai Hospital ethics committee, and
informed consent was obtained from the participants.
American Journal of Orthodontics and Dentofacial Orthopedics
September 2010
Fig 1. Mandibular Schwarz appliance used in this study.
After initial recording of the data, the patients were ran-
domized to 2 groups: those treated with Schwarz
appliances (expanded group) and a nonexpanded control
group (nonexpanded group) (Fig 1). Records were gath-
ered at 2 times from both groups. For the expanded
group, the first records were gathered before treatment
(T0); the second set was obtained during a retention pe-
riod of approximately 9 months after 6 to 12 months of
expansion (T1). In the control group, 2 sets of records
were obtained approximately 13 to 21 months apart.
The expanded group included 14 patients (6 boys, 8 girls)
with average ages of 7 years 11 months at T0 and 9 years
8 months at T1. The nonexpanded group received no
treatment and included 14 patients (6 boys, 8 girls)
with average ages of 8 years at T0 and 9 years 8 months
at T1. The expanded group used a Schwarz expansion
appliance on the maxillary and the mandibular dentitions
to relieve anterior crowding. The maxillary dental arches
were also expanded with a Schwarz appliance in all
expanded group patients to maintain the buccolingual
relationships of occlusal contact in the posterior teeth
during expansion. The patients wore the expansion
appliances at night. The treatment period was approxi-
mately 1 year. The appliance was activated by rotating
its screws once a week (90 for 0.175 mm). The expan-
sion plates were adjusted when the appliance disturbed
an erupting tooth or did not fit in the dental arch. A
new appliance was fabricated when the screw reached
its limit.
After 12 months of expansion, the screw of the
Schwarz appliance was fixed with composite (cured)
and used as a retainer. The patients wore Schwarz appli-
ances only to prevent any effects from other appliances.
Lateral cephalometric radiographs were traced by 1
investigator (K.T.) to minimize error in measurement.
Sixteen points were digitized on each cephalometric ra-
diograph, and 12 cephalometric measurements were
made.
American Journal of Orthodontics and Dentofacial Orthopedics Tai et al 262.e3
Volume 138, Number 3

Fig 2. A, Flow chart illustrating the methods used to convert CBCT-derived DICOM data into polygon
data. B, The ICP method at the cranial base. Superimposition was performed in all areas except for
the edge of the cranial base that experienced growth. The green area shows that superposition (or
registration) was performed within 6 0.50 mm. The yellow area shows the range from 0.50 to 1.00
mm. The light blue area shows the range from 0.50 to 1.00 mm. C, 3D images show the superim-
position of T1 on T0.

Three measurements were made on the mandibular
casts: arch crowding,37 arch perimeter,27,28 and arch
length.27,28 The dental cast measurements were made
with Digimatic calipers (NTD 12-15PMX, Mitsutoyo,
Kanagawa, Japan) accurate to 0.01 mm.
The CBCT images at T0 were taken at average ages
of 7 years 11 months (expanded group) and 8 years
0 months (nonexpanded group), and, in both groups,
the CBCT images at T1 were taken at an average age
of 9 years 8 months.
262.e4 Tai et al
The head position was oriented so that the Frankfort
plane was parallel to the floor in a seated position, and
an image was taken at the intercuspal position using
CB MercuRay (Hitachi Medical, Tokyo, Japan).
To transform the digital imaging and communica-
tion in medicine (DICOM) data from the CBCT images
into polygon data, 5 software programs were used
Volume-Rugle (Medic Engineering, Kyoto, Japan), Mi-
croAVS (KGT, Tokyo, Japan), VVD2RGL, Point-
Rugle, and 3D-Rugle (Medic Engineering) (Fig 2, A).
The iterative closest point (ICP) method38,39 can
superimpose precisely with repeatability because
numerous corresponding points are used to compare
with point-based registrations.40,41 To superimpose
two 3-dimensional (3D) images at T0 and T1, the ICP
method was used (Fig 2, B and C). Furthermore, to
superimpose 2 separate multi-planar reconstruction
(MPR) images accurately, specific points of the cranial
base were used as the reference points for superimposi-
tion, because the cranial base is not greatly influenced
by growth (Figs 2, B and C). As a result, accurate super-
imposition of 2 separate MPR images is possible. Fur-
thermore, to enhance the accuracy of the ICP method,
specific points of the cranial base were used as reference
points for registration (superimposition), because the
cranial base is not greatly influenced by growth
(Fig 2, B and C).42-45 Then the combined images were
cut down an arbitrary plane and made into 2 units.
The MPR images, which have excellent dimensional
accuracy, were used to compare the data at T0 and T1.46
A slice plane perpendicular to the occlusal plane,
passing through both sides of the mesiobuccal cusp
tips of the mandibular first molars, was prepared for
the measurements. The 3D-Rugle software program
was used for the measurements, and the following
distances were measured at T0 and T1. Ten points of
interest were measured including mandibular first-
molar crowns, cementoenamel junctions (CEJs), roots,
buccal and lingual alveolar processes, inner and outer
surfaces of the mandibular bodies, zygomatic bones,
condylar heads, and antegonial notches (Table I;
Fig 3, A and B).
In addition, the distances of the crowns, CEJs, labial
and lingual alveolar processes, and inner and outer
surfaces of the mandibular bodies of the mandibular first
deciduous molars were measured at a point 18 mm
anterior from the mesial cusps of the mandibular first
molars.
To determine whether there was a relationship be-
tween the amount of expansion or tipping and the
change in cortical bone thickness at the mandibular first
molars, the mandibular first deciduous molars, and the
mandibular second deciduous molars, axial CBCT
American Journal of Orthodontics and Dentofacial Orthopedics
September 2010
Table I. Summary of measured parameters and associ-
ated landmarks
Landmark for
parameter Measured landmarks
1. M1Crown Distance between crowns (lingual surfaces of
the mandibular right and left first molar
crowns 3 mm above the CEJ)
2. M1CEJ Distance between the CEJs
3. M1LAP Distance between lingual surfaces of the
alveolar processes at the mandibular right
and left first molar areas 2 mm below the CEJ
4. M1BAP Distance between buccal surfaces of the
alveolar processes at the mandibular right
and left first molar areas 2 mm below the CEJ
5. M1Root Distance between roots (the distance between
the mandibular right and left first molar roots
7 mm below the CEJ)
6. M1IMB Distance between inner surface of the
mandibular bodies 13 mm below the CEJ
7. M1OMB Distance between outer surface of the
mandibular bodies 13 mm below the CEJ
8. Zyg Distance between zygomatic bones at the
outermost part of the zygomatic buttresses
9. CoO Distance between the outermost part of the
condylar heads
10. Ag Distance between antegonial notches
M1, Mandibular first molar; LAP, lingual alveolar process; BAP, buc-
cal alveolar process; IMB, inner mandibular body; OMB, outer man-
dibular body; Zyg, zygomatic bone; CoO, outermost condylar head;
Ag, antegonial notch.
images were taken at 2 and 13 mm below the CEJ
(Fig 3, C).
One examiner (K.T.) made all measurements to
eliminate interexaminer errors. To identify systematic
errors and compare measurement accuracy, intraexa-
miner reliability was evaluated. Sources of error in-
cluded landmark location, anatomic contours, tracing
from the cephalograms, digitizing the cephalograms,
data conversion from the different software programs,
all linear and angular measurements from the CBCT,
and all linear measurements from the dental casts.
Also, to prevent bias in the measurement of the ex-
panded and nonexpanded groups, the investigator was
blinded. Tracing and digitizing errors of cephalograms,
data conversion errors from the different software pro-
grams, linear and angular measurement errors of the
CBCT, and all linear measurements from the dental
casts were determined by remeasurement at least twice
on 2 separate occasions, 2 weeks apart. Five randomly
selected subjects from each group were measured at
least twice on 2 separate occasions, 2 weeks apart, by
the same investigator. No statistically significant differ-
ence was found for any measurement by using intraclass
correlation coefficients.47
American Journal of Orthodontics and Dentofacial Orthopedics Tai et al 262.e5
Volume 138, Number 3

Fig 3. Diagram showing reference points and lines. A, A plane slicing perpendicular to the occlusal
plane and passing through both sides of the mesiobuccal cusp tips of the mandibular first molars was
set for measurements. The distances between the first molar crowns, CEJs, roots, alveolar pro-
cesses, mandibular bodies, and the zygomatic bones were measured on this plane. B, A plane par-
allel to the long axis of the ramus bone was used to measure the distance between the condylar
heads and the antegonial notches. C, An axial plane depicting measurements at 2 and 13 mm below
the CEJ. BMW, buccal mandibular width: distance between the right and left buccal cortical plates;
LMW, lingual mandibular width: distance between the right and left lingual cortical plates.
262.e6 Tai et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2010

Table II. Comparison of cephalometric and cast measurements between groups

Nonexpanded group Expanded group

Changes with Changes with

T0 T1 growth T0 T1 treatment
Mann-Whitney
Group Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD U test (significance)

Angular skeletal ( )
Facial angle 84.39 2.64 83.80 2.59 0.59 0.39 83.57 2.63 83.71 2.61 0.14 0.12 NS
Angle of convexity 4.21 1.89 3.80 1.79 0.41 0.77 4.17 1.32 3.61 1.29 0.56 0.40 NS
FMA 29.79 2.64 30.26 2.54 0.47 0.93 28.90 2.28 29.49 2.25 0.59 0.51 NS
SNA 82.16 3.73 82.23 3.66 0.07 0.05 81.56 4.05 82.11 4.02 0.55 0.11 NS
SNB 80.01 2.43 80.12 2.32 0.11 0.09 79.59 3.45 80.01 3.39 0.43 0.14 NS
ANB 2.15 0.73 2.11 0.64 0.04 0.04 1.97 1.55 2.10 1.49 0.13 0.10 NS
Angular and linear dental
U1 to SN (mm) 100.90 11.60 104.52 10.50 3.62 3.59 101.19 7.82 105.14 7.01 3.95 3.39 NS
Interincisal angle ( ) 132.03 9.04 125.54 10.52 6.49 3.02 133.37 7.54 124.86 7.74 8.51 5.53 NS
IMPA ( ) 92.60 7.11 93.89 7.52 1.29 2.10 93.59 5.45 96.36 4.85 2.78 1.91 NS
L1-APo ( ) 25.19 2.84 25.73 2.63 0.54 0.45 24.29 2.36 25.28 2.28 0.99 0.50 NS
L1-APo (mm) 3.06 1.50 3.39 1.40 0.34 0.29 2.97 1.81 3.70 1.52 0.73 0.45 NS
Linear soft tissues (mm)
Upper lip E-line 2.00 1.71 1.37 1.68 0.63 0.50 2.08 1.90 1.60 1.75 0.48 0.35 NS
Lower lip E-line 2.61 2.04 1.91 1.67 0.71 0.63 2.95 1.73 2.39 1.57 0.56 0.50 NS
Mandibular cast measurements (mm)
Arch crowding 3.83 0.87 3.17 1.27 0.66 0.50 3.59 1.21 0.78 0.70 2.80 1.14 *
Arch perimeter 66.26 4.77 67.04 4.95 0.78 0.65 66.35 3.36 70.11 3.58 3.76 1.62 *
Arch length 23.06 2.28 23.87 2.56 0.81 0.75 24.92 2.11 25.84 1.95 0.92 0.80 NS

*P \0.05; NS, not significant.

Statistical analysis were no significant differences for the mandibular bod-

Descriptive statistics were calculated for each mea-
surement. The data were analyzed by using a statistical
software package (version 16.0, SPSS, Chicago, Ill).
Treatment changes between the 2 groups and between
T0 and T1 were analyzed with the Mann-Whitney U
test. A value of P \0.05 was considered significant.
RESULTS
Table II shows the measurements at T0 and T1 of
both groups. There were no significant skeletal, dental,
and soft-tissue lip profile changes from T0 to T1. No
mandibular rotation or displacement was seen between
T0 and T1. However, in the mandibular cast measure-
ments of arch crowding and arch perimeter, there were
statistically significant changes from T0 to T1 in the
expanded group.
The Schwarz expanded group showed marked ex-
pansion compared with the nonexpanded group. The in-
termandibular first molar lengths increased by 5.41 mm
at the crown level, 4.39 mm at the CEJ, 2.40 mm at the
root, 3.75 mm at the mandibular alveolar lingual point,
and 3.84 mm at the mandibular alveolar buccal point.
There were significant (P \0.05) differences between
the groups for teeth and alveolar bone. However, there
ies (P 5 0.695), zygomatic bones (P 5 0.893), condylar
heads (P 5 0.613), and antegonial notches (P 5 0.724)
(Table III).
The mandibular first deciduous molars had also
expanded. However, because of root resorption, the
measurement at the root was not performed. For the ex-
panded group, the intercrown width of the mandibular
first deciduous molar crowns increased by 5.90 mm,
the width at the CEJ by 4.69 mm, the width at the man-
dibular alveolar lingual points by 4.20 mm, and the
mandibular alveolar buccal points by 4.25 mm. Because
of root resorption during treatment, measurement of the
mandibular first deciduous molar roots was not possible.
There were significant (P \0.05) differences between
the groups in regard to the teeth and alveolar bone
(Table III). The increased width between the mandibu-
lar first deciduous molars was greater than that of the
mandibular first molars. However, there was no signifi-
cant (P .0.05) difference between those 2 measure-
ments in the expanded group.
The CBCT images can show precise changes in
internal structures, including tooth roots; the center of
rotation of teeth expanded by the Schwarz appliance
was below the root tip. By plotting the points of crowns,
necks, and roots, a straight line was obtained. By using
American Journal of Orthodontics and Dentofacial Orthopedics Tai et al 262.e7
Volume 138, Number 3

Comparison of the amount of expansion be-

Table III. teeth. In nonextraction treatment, expansion of the man-
tween the groups dibular arch can be a treatment option. Great growth
Nonexpanded Expanded
changes in the dentoalveolar area occur during eruption
group group Mann-Whitney of the permanent teeth.49 To take advantage of this pe-
U test riod, a Schwarz appliance was used to develop the den-
Mean SD Mean SD (significance)
toalveolar area. Furthermore, a careful diagnosis was
M1Crown (mm) 0.83 0.28 5.41 1.61 * made, including an analysis of the profile and the rela-
M1CEJ (mm) 0.80 0.39 4.39 1.46 * tionships between the dimensions of dentition, jaws,
M1LAP (mm) 0.81 0.43 3.75 1.58 * and skull.
M1BAP (mm) 0.76 0.39 3.84 1.74 *
M1Root (mm) 0.77 0.30 2.40 1.22 *
The Schwarz appliance can correct or improve
M1IMB (mm) 0.69 0.30 0.66 0.39 NS crowding with night-time wear only. The appliance
M1OMB (mm) 0.82 0.52 0.73 0.36 NS was activated once each week without causing pain. In
Dm1Crown (mm) 1.18 0.50 5.90 1.61 * this study, the average age of the expansion group was
Dm1CEJ (mm) 1.12 0.71 4.69 1.19 * 7 years 11 months, and the average treatment time was
Dm1LAP (mm) 0.99 0.32 4.20 1.74 *
Dm1BAP (mm) 1.02 0.54 4.25 1.54 *
6 to 12 months plus a 9-month retention period.
Dm1IMB (mm) 0.89 0.62 0.88 0.49 NS After phase I treatment, the appliances were fixed
Dm1OMB (mm) 0.85 0.36 0.91 0.61 NS with composite (cured) and used as retainers, or a new
Zyg (mm) 3.68 1.02 3.70 1.04 NS Hawley retainer was delivered. The patients were ad-
CoO (mm) 3.64 1.06 3.68 1.27 NS vised to wear the retainers every night. They were re-
Ag (mm) 3.59 0.79 3.64 1.74 NS
called for evaluation of relapse every 3 months before
M1, Mandibular first molar; Dm1, mandibular first deciduous molar; the second phase of treatment. Every 6 to 12 months
LAP, lingual alveolar process; BAP, buccal alveolar process; IMB, in- during the retention period, progress records were taken
ner mandibular body; OMB, outer mandibular body; Zyg, zygomatic
to verify whether extraction would be needed in the sec-
bone; CoO, outermost condylar head; Ag, antegonial notch.
*P \0.05; NS, not significant. ond phase of treatment. Every patient was reminded that
wearing the retainers was the most important factor in
this line, the center of rotation was determined to be maintaining the expansion.
2.49 mm (SD, 1.13 mm; range, 0.08-4.21 mm) below To superimpose two 3D images, we used the
the root tip on the long axis of the tooth (Fig 4). This re- surface-based registration with the least-squares
sult tends to be considerably influenced by the length of method. We chose the ICP method for this research.
the first molar. The average length of the first molar in The special feature of this technique is the ability to
this study was 19.10 mm (SD, 2.6), which was similar precisely superimpose images of growing subjects be-
to the Japanese average reported by Kamijo.48 cause it does not depend on anatomic landmarks but
In the expanded group, the mandibular right first uses a best fit of the hard-tissue surface shapes that
molar was uprighted by 8.5 (SD, 1.5 ; range, 6.2 - were not greatly influenced by growth.50 As a result,
11.3 ), and the clinical crown inclination value became systematic errors are greatly reduced even for growing
24.0 (SD, 3.8 ; range, 28.9 to 18.1 ). The mandib- subjects. However, some patients required manual reg-
ular left first molar was uprighted by 8.9 (SD, 1.4 ; istration by an experienced investigator. Pfuger et al51
range, 6.7 -11.2 ), and the clinical crown inclination reported that sometimes manual registration is more
value became 22.5 (SD, 3.4 ; range, 29.1 to precise than automatic registration. Confirmation by
17.5 ). The original angulation of the mandibular right the investigators observations of the image registration
first molar was 32.5 (SD, 3.8 ; range, 37.4 to is important for this method. As a result, combining
26.6 ), and the mandibular left first molar was 31.4 manual and automatic operations should increase the
(SD, 3.4 ; range, 38.0 to 26.4 ) (Fig 4). accuracy of this modality in the future.
When comparing the T0 and T1, the buccal mandib- Our objective was to analyze the efficacy of the
ular width (BMW) and lingual mandibular width Schwarz appliance by using a new method of CBCT su-
(LMW) values at 2 mm and 13 mm below CEJ level, perimposition. However, the results should be carefully
there were significant (P \0.05) differences 2 mm be- interpreted, because our sample size was small. It would
low the CEJ in the expanded group (Table IV). be beneficial to include more subjects to obtain more re-
liable data. Another limitation of the study was the lack
of data after expansion (6-12 months) because parents
DISCUSSION were unwilling to have additional CBCT images taken
Lack of adequate space in the mandibular arch is of- of patients with Angle Class I malocclusions with nor-
ten a critical factor in the decision of whether to extract mal vertical dimensions and no posterior crossbites.
262.e8 Tai et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2010

Fig 4. A, The alveolar process was expanded along with movement of the teeth; B, by connecting the
plotting points of crowns, CEJs, and roots, a straight line was obtained, and the center of rotation was
determined to be 2.49 mm below the root tip on the long axis of the tooth.

Table IV. Comparison of mandibular width measurements

Nonexpanded group Expanded group

Changes with Changes with

T0 T1 growth T0 T1 treatment
Mann-Whitney
Group Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD U test (significance)

2mm below the CEJ (mm)

BMW Dm1 39.44 5.52 40.46 5.68 1.02 0.54 38.87 5.58 43.12 5.61 4.25 1.54 *
LMW Dm1 23.22 6.03 24.21 6.12 0.99 0.32 22.47 4.84 26.67 4.75 4.20 1.74 *
BMW Dm2 49.12 4.05 50.04 4.15 0.92 0.53 48.12 3.87 52.22 4.05 4.10 1.68 *
LMW Dm2 29.41 4.34 30.30 4.19 0.88 0.48 28.04 3.13 32.07 3.56 4.02 1.35 *
BMW M1 57.91 5.28 58.72 5.22 0.81 0.43 56.04 4.51 59.88 5.12 3.84 1.74 *
LMW M1 34.06 4.84 34.81 4.79 0.75 0.40 32.49 3.29 36.24 3.98 3.75 1.58 *
13mm below the CEJ (mm)
BMW Dm1 42.29 5.37 43.14 5.57 0.84 0.33 43.22 6.61 44.08 6.41 0.86 0.64 NS
LMW Dm1 19.26 4.11 20.07 3.81 0.81 0.49 20.40 4.17 21.22 4.33 0.82 0.54 NS
BMW Dm2 57.17 7.92 57.95 7.77 0.78 0.50 56.82 9.33 57.62 9.11 0.80 0.60 NS
LMW Dm2 29.66 3.34 30.41 3.57 0.75 0.40 28.84 3.80 29.62 3.83 0.78 0.35 NS
BMW M1 66.89 9.41 67.59 9.53 0.71 0.49 65.03 5.16 65.76 5.20 0.73 0.36 NS
LMW M1 36.02 5.15 36.71 5.12 0.69 0.30 34.02 3.81 34.67 3.80 0.66 0.39 NS

BMW, Buccal mandibular width; LMW, lingual mandibular width; Dm1, first deciduous molar; Dm2, second deciduous molar; M1, first molar.
*P \0.05; NS, not significant.

In regard to the amount of expansion produced by
the Schwarz appliances, Motoyoshi et al32 reported
that the mean mandibular first molar inclination was in-
creased by 10.16 , and the mean increase in intermolar
width was 5.42 mm after activation for 6 months to 1
year. Moreover, Sekizaki52 reported that the distance
between the CEJ of the mandibular first molars in-
creased by 4.15 mm. In our research, the increase in mo-
lar inclinations was 8.7 (SD, 1.4 ; range, 6.2 -11.3 ),
and the distance between the CEJ of the mandibular first
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 3
molars was 4.39 mm (SD, 1.46; range, 2.84-7.71 mm).
In comparison with previous studies, our data showed
no significant differences.
In the mandibular cast measurements, the arch-
length change was not significant because the Schwarz
appliance expanded the mandibular width transversely
rather than sagittaly. From the cephalometric measure-
ments, in the expanded group, IMPA and L1-APo in-
creased slightly more than in the nonexpanded group,
but the difference was not significant. Furthermore,
the soft-tissue lip profile changes were not significant
because of corresponding growth of the patients nose.
Using CBCT, we demonstrated that the mandibular
bodies were not affected by the Schwarz appliance even
when the teeth and the alveolar base had expanded.
Some reports have stated that the effects of the Schwarz
appliance on mandibular expansion were localized in
the alveolar bone and might cause tooth inclinations.2,5
In our research, although the dental arches expanded
mainly by tooth inclination, the distance between the
root tips also increased. Furthermore, the amounts of
displacement of the alveolar bone were almost the
same on the buccal and lingual sides.52 This similarity
might be due to the remodeling of the alveolar process.
The expansion of buccal alveolar plates gives us in-
formation about the alveolar process of bending or tip-
ping. Any additional expansion beyond that of sutural
separation could be from tipping of the alveolar
ridges.53 It seems reasonable that the thinner cervical
parts are more easily bent outward by the pressure of
the plate than the thick apical ones. Hamada et al54 re-
ported that the alveolar process changed with mandibu-
lar expansion in an animal experiment. However, no
expansion effect induced by the Schwarz appliance
was seen in the alveolar base and mandible bodies. Fur-
thermore, they observed genesis of new bone (osteoid)
on the bucccal side near the alveolar crest of the buccal
alveolar bone and absorption of the bone on the lingual
side near the alveolar crest of the lingual alveolar bone,
respectively, in the expansion group. From our study,
the cortical bone near the alveolar bone crest showed
the greatest expansion. However, below the center of ro-
tation of tooth movement, no significant change of the
buccal and lingual cortical bones was found (Table IV).
The lingual crown inclination of normally occluded
mandibular posterior teeth progressively increases from
the canines through the second molars. Andrews55 sug-
gested that the buccolingual inclination of the mandib-
ular first molar is approximately 30 . In our study,
the mandibular molars after treatment were slightly up-
righted approximately to 23 , not straight upright (ap-
proximately 0 to 12 ), which would be detrimental to
masticatory mandibular movements.56
Tai et al 262.e9
The preadjusted appliance system is a development of
the edgewise bracket. Extra torque is built into the
McLaughlin, Bennett and Trevisi (MBT) bracket system
in the incisor and molar regions compared with the orig-
inal straight-wire appliance. In the MBT bracket system,
to prevent extrusion of the lingual cusp of the maxillary
first molar, 14 torque is built in instead of 9 . Accord-
ingly, the mandibular first molar torque is reduced from
30 to 20 .57
In future studies, we will include long-term data
such as postexpansion measurements. This study was
more focused on evaluating the effect of the Schwarz
appliance with a new CBCT superimposition method.
CONCLUSIONS
Our findings from this preliminary study are
summarized as follows.
1. CBCT images can show precise changes in internal
structures, including tooth roots.
2. There were no significant skeletal, dental, and soft-
tissue lip profile changes in the expanded group.
However, in the mandibular cast measurements,
arch crowding and arch perimeter had statistically
significant changes.
3. A Schwarz appliance expands the mandibular first
molars and mandibular first deciduous molars
mainly by inclination movement; in addition, it
slightly expands the alveolar process and the root
tip. Mandibular body, zygomatic bones, condylar
heads, and mandibular antegonial notches are not
significantly affected by the Schwarz appliance.
4. The center of rotation of a tooth by Schwarz expan-
sion was observed 2.49 mm below the root tip on
the long axis, but this tends to be considerably influ-
enced by the length of the first molar.
5. In the expansion group, there were significant
changes at 2 mm below the CEJ in buccal and lin-
gual mandibular widths compared with 13 mm
below the CEJ.
We thank Toyohisa Tanijiri (Medic Engineering,
Kyoto, Japan) for developing the software, Kazuo Seki-
zaki for his suggestions, and the staff and x-ray techni-
cians of the Tai orthodontic office for their valuable help
and assistance throughout this study.
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